Version No.

| Comp/Dec/Int/3069

Employee Code:.

For Ocial Use Only

Policy Service Request

Form 1A

Branch Name:

(Change in Name and Address)

Date & Time:

(* Indicates Required Fields)

Received by

Signature:
Branch Stamp:
Accepted
Rejected

Policy Number *: ______________________________ Email ID: ___________________________________________

Policy Holder's Name* : ____________________________________________________________________________
Contact Nos. Mobile* : _____________________ O: _____________________ Res: _____________________ (Mobile No is preferable)
E-Insurance Account No.:

1. Contact details provided herein will be updated for all future communication. For the customer registered under National Do Not Call
Registry, this response will be treated as valid discharge.
2. The change will be eected in all the policies where client exists.

Correction in Name
Policy Holder

Life Assured

Nominee/Beneciary

Appointee

General Rules
For Married women with change in surname, marriage certicate is mandatory. For the other request involving signicant name change a
Gazette Copy is required.
Name to be change to* : _________________________________________________________________________

Change in Correspondence Address(Multiple selections allowed in case of common address)

Policy Holder

Life Assured

Nominee/Beneciary

Appointee

General Rules
The change will be eected in all the policies where the client code exists. Self attested documentary proof of the new address is
mandatory. Contact us at any of our touch points to know the list of acceptable address proofs.
Address*: __________________________________________________________________________
___________________________________________________________________________________
Email ID: _________________________________________, Contact No* : _______________________

Declarations
Declaration of the Policyholder:
I have understood the meaning and scope of the change request form and take complete responsibility of the change submitted by me.
Any changes in the policy or personal details are subjected to the policy terms & conditions and relevant underwriting guideline.
Signature of Life Assured 1* :
Date* :
Place* :

Signature of Life Assured 2 (In case Joint Life)* :

In case policy is assigned Signature of Assignee with seal * :

Date * :
Place*:
Declaration to be made by third party where the policy holder has axed his/her thumb impression/ has signed in vernacular:
I hereby declare that I have explained the contents of this application form to the Policy Holder in _________________________________

*language and have truthfully recorded the answers provided to me. I further declare that the policy holder has signed/ axed his/ her
thumb impression in my presence.
Name* : ________________________________ Date*: _____________ Place*:______________________________
Signature *:
Address *: ____________________________________________________________________________________________________
HDFC Standard Life Insurance Company Limited. Regd. Off: Lodha Excelus, 13th Floor, Apollo Mills Compound, N.M.Joshi Marg, Mahalaxmi, Mumbai-400 011.

Customer Acknowledgement Copy (Policy Servicing Form)

Policy No.: ____________ Policyholder Name _______________________________________________
PS Request: __________________________________________________ Interaction ID No.: __________
Documents accepted: ___________________________________________________________________
Customer Relations Ocer:

Date:

Time:

Branch Stamp

Version No. | Comp/Dec/Int/3070

Policy Service Request Form 1B

Employee Code:.

For Ocial Use Only

Signature:

Branch Name:

(Change in Nominee & Nominee

DoB)

Date & Time:

(* Indicates Required Fields)

Received by

Branch Stamp:
Accepted
Rejected

Policy Number *: ______________________________ Email ID: _________________________________________

Policy Holder's Name *: ___________________________________________________________________________
Contact Nos. Mobile *: _______________________ O: _____________________ Res: ____________________ (Mobile No is preferable)
E-Insurance Account No.:

1. Contact details provided herein will be updated for all future communication. For the customer registered under National Do Not Call
Registry, this response will be treated as valid discharge.
2. The change will be eected in all the policies where client exists.

Addition or change in Nominee / Beneciary

Change in Nominee/ Beneciary Date of Birth In case, the nominee/ beneciary is a minor, please
ll up the appointee details below.
1. Nominee/ Beneciary Name*:
1. Nominee/ Beneciary Name*:
____________________________________________ ____________________________________________
Address * :____________________________________ Address* :______________________________________
____________________________________________ ____________________________________________
Relationship to Life Assured * : _____________________ Relationship to Life Assured * : _____________________
Percentage of entitlement * : _______________________ Percentage of entitlement * : _______________________
In case of change in date of birth of nominee/ beneciary
In case of change in date of birth of nominee/ beneciary
Old DOB: __/__/____ (dd/mm/yyyy)*
Old DOB: __/__/____ (dd/mm/yyyy) *
New DOB: __/__/____ (dd/mm/yyyy) *
New DOB: __/__/____ (dd/mm/yyyy) *

Addition/ Change of Appointee

Change of Appointee Date of Birth

Appointee Name* : Mr/Mrs/Ms:__________________________________________________________

Address* : __________________________________________________________________________
_____________________________________________________________________
Email ID * : _____________________________________________________________
Appointee Relation to Nominee/Beneciary * :_______________________________________________________
In case of change of DOB of Appointee, Old DOB ____/____/____ (dd/mm/yyyy)* New DOB ____/____/____ (dd/mm/yyyy)*
Declaration of Appointee:
I hereby accept my appointment as an appointee to receive the proceeds under the policy on behalf of Beneciary/Nominee who is minor.
Appointee Signature * :

Date * :

Place *:

Declaration
Declaration of the Policyholder:
I have understood the meaning and scope of the change request form and take complete responsibility of the change submitted by me.
Any changes in the policy or personal details are subjected to the policy terms & conditions and relevant underwriting guideline.
Signature of Life Assured 1*:
Signature of Life Assured 2 ( In case Joint Life)* :
Date *:
Place *:
In case policy is assigned Signature of Assignee with seal:
Date *:
Place *:
Declaration to be made by third party where the policy holder has axed his/her thumb impression/ has signed in vernacular:
I hereby declare that I have explained the contents of this application form to the Policy Holder in ___________________* language and
have truthfully recorded the answers provided to me. I further declare that the policy holder has signed/ axed his/ her thumb impression
in my presence.

Name *: ________________________________ Date*: _____________ Place*:______________________________

Signature *:
Address *: _____________________________________________________________________________________________________
HDFC Standard Life Insurance Company Limited. Regd. Off: Lodha Excelus, 13th Floor, Apollo Mills Compound, N.M.Joshi Marg, Mahalaxmi, Mumbai-400 011.

Customer Acknowledgement Copy (Policy Servicing Form)

Policy No.: ____________ Policyholder Name _______________________________________________
PS Request: __________________________________________________ Interaction ID No.: __________
Documents accepted: ___________________________________________________________________
Customer Relations Ocer:

Date:

Time:

Branch Stamp

Version No. | Comp/Dec/Int/3071

Employee Code:.
Signature:
Branch Stamp:
Accepted
Rejected

For Ocial Use Only

Policy Service Request

Form 1C

Branch Name:

(Major Alteration)

Date & Time:

(* Indicates Required Fields)

Received by

Policy Number *: ______________________________ Email ID: _________________________________________

Policy Holder's Name *: ___________________________________________________________________________
Contact Nos. Mobile *: ___________________ O: _____________________Res: ______________________(Mobile No is preferable)
E-Insurance Account No.:

1. Contact details provided herein will be updated for all future communication. For the customer registered under National Do Not Call
Registry, this response will be treated as valid discharge.
2. The change will be eected in all the policies where client exists.

Reduction in Sum Assured

Please reduce the Sum Assured of my policy from Rs. ______________________ to Rs. _____________________

Increase in Premium
Please increase the premium of my policy from Rs. ______________________ to Rs. _______________________

Decrease in Term
Please decrease the term of my policy from __________ years to ___________ years.

Deletion of Rider
I would like to cancel the below riders from my policy
1. _____________________ 2. __________________ 3.______________________ 4. _____________________

Change in frequency
Please change the frequency of premium payment of my policy to
Annual

Half Yearly

Quarterly*

Monthly*

* Auto debit is mandatory for monthly mode (all plans) and quarterly mode (specied plans).

Loan or Surrender Quote (tick the one applicable)

I would like to avail of a loan against the policy. Kindly provide me a loan quote.
I would like to know the surrender value of my policy. Kindly provide me the surrender quote.
Request for changes in policy benets is allowed only after completion of Six months from the date of commencement of policy
The request should be submitted at least 15 days prior to the next premium due date.
For policy alterations where auto debit method of payment is active, the current mandate will be de-activated post policy alteration. A fresh auto Debit Mandate will be required if
you wish to opt for or continue with auto debit facility for your policy. This should be submitted at any HDFC Life branch at least 30 days prior to the next premium due date.
Request for change in certain policy benets must be accompanied by the original policy document.
Policy servicing charges may be levied as applicable. Please refer to your policy document for details.
Declarations for Suvidha and Conventional plans:
I/We understand the reduction in premium will reduce the Sum Assured as per the regulatory limits. I/We agree that reducing the Sum Assured will change the future benets.
Reduction in premium for SUVIDHA plan is permissible only if the Policy Commencement date is less than or equal to 31-10-2007.
Reduction in premium for SAP plan is not allowed if the policy is converted after 01-08-2009.

Declarations
Declaration of the Policyholder:
I have understood the meaning and scope of the change request form and take complete responsibility of the change submitted by me.
Any changes in the policy or personal details are subjected to the policy terms & conditions and relevant underwriting guideline.
Signature of Life Assured 1 *:
Date *:
Place *:

Signature of Life Assured 2 (In case Joint Life) *:

In case policy is assigned Signature of Assignee with seal *:

Date *:
Place *:

Declaration to be made by third party where the policy holder has axed his/her thumb impression/ has signed in
vernacular:
I hereby declare that I have explained the contents of this application form to the Policy Holder in __________________language
*
and
have truthfully recorded the answers provided to me. I further declare that the policy holder has signed/ axed his/ her thumb impression
in my presence.
Name *: ________________________________ Date*: _____________ Place*: _____________________________
Signature *:
Address* : _____________________________________________________________________________________________________
HDFC Standard Life Insurance Company Limited. Regd. Off: Lodha Excelus, 13th Floor, Apollo Mills Compound, N.M.Joshi Marg, Mahalaxmi, Mumbai-400 011.

Customer Acknowledgement Copy (Policy Servicing Form)

Policy No.: ____________ Policyholder Name _______________________________________________
PS Request: __________________________________________________ Interaction ID No.: __________
Documents accepted: ___________________________________________________________________
Customer Relations Ocer:

Date:

Time:

Branch Stamp